Getting Ready for RUBI via Telehealth

Most of us thrive on structure, routine, and just “having a plan.” But with the coronavirus health crisis, the world–and our lives–seem to be changing day to day, leaving many of us feeling flustered and off balance. One way I am attempting to regain control of my routine is to establish for myself a “new normal.” Right now, that means transitioning my practice to a telehealth-delivery care model for RUBI.

While I have been thinking about, and taking necessary steps toward, adding telehealth delivery of RUBI to my clinic practice for months (ok, maybe years!), I somehow always found excuses to put it on the back-burner. Until now… nothing like an international health crisis to motivate change!

Living in Seattle, I am home to one of the epi-centers of the Coronavirus epidemic in the United States. As a result, our clinic halted all in-person visits as of Tuesday, March 16th. This meant I was leaving all my families (22 to be exact!) in the lurch, literally in the middle of their participation in the RUBI program. This was especially difficult since schools were closing for 6 weeks and daily routines were about to be turned on their heads with weeks-long stretches of “unstructured” time. Families were particularly vulnerable and I knew transitioning all patient care to telehealth was crucial.

My hope with this 3-part blog series is that I can pass along some beneficial lessons as I make this transition, so that I can save you some time and you can have a smooth roll-out yourselves.

This first blog will focus on the “behind the scenes” logistics, such as billing considerations, room setup, as well as setting up our clients/patients for success. Next week, I will target RUBI-specific telehealth implementation considerations. The final blog will be “lessons learned” to review barriers, challenges, and successes from my first forays into RUBI via telehealth.

Learning about Telehealth from Literature

Of course, any good starting place involves learning from the experts and what has already been written on telehealth services. So, I want to start by directing you to some seminal readings. The American Psychological Association (APA) has a plethora of resources, starting with their Guidelines for the Practice of Telepsychology.

I would also be remiss to not include the reference for our pilot trial of RUBI delivered via telehealth: Bearss K., Burrell T.L., Challa S.A., Postorino V., Gillespie S.E., Crooks C., & Scahill, L. (2018). Feasibility of parent training via telehealth for children with autism spectrum disorder and disruptive behavior: A demonstration pilot. Journal of Autism and Developmental Disorders, 48, 1020–1030. https://doi.org/10.1007/s10803-017-3363-2. This was our own first go at delivering RUBI via telehealth. In short, it worked GREAT with very few modifications required. Whew!

Who Should We Do Telehealth With?

As providers, we may think telehealth is a great backup to providing care in-clinic and so it’s hard to imagine that a family might turn us down. I would expect that most families say yes, but it is important to actively assess family interest and give them the space to refuse this format of service. Reasons for rejection may span from a family not feeling comfortable with providers seeing their home, logistical constraints such as not having the right technology to participate or having a home structure that would make it difficult to participate. Other families may just be focused on getting by in the age of coronavirus, juggling potential changes in school, “stay at home” mandates, and changes in employment. As providers, we may feel a family is especially in need during these uncertain times, but we should respect our families’ choices and ensure we are setting up everyone for success by confirming telehealth delivery of RUBI at this moment in time is a good fit.

How are We Going to Bill for That?

There may not be one simple answer, but the first step is to provide patients with the understanding that telehealth can be a billable service and informing them that they have the right to check their insurance coverage and that we, as a clinic, will be doing the same. A script I use during my initial phone intake is: “Most, but not all, insurance plans cover telehealth services. We strongly recommend you check with your insurance plan. If you have questions about billing, you also can speak with someone from our billing department at XXX-XXX-XXXX.”

How approval plays out with private insurance likely varies by state and provider (e.g. psychologist vs. masters-level BCBA). Additional guidance specifically on providing telehealth services under medicare can be found here.

For RUBI telehealth sessions, I will be billing the psychologist CPT codes 90846 (family therapy without patient) or 90847 (family therapy with patient) and my electronic billing system is set up for me to add a CPT modifier of “GT Telemedicine”.

Another fantastic resource, with up-to-date state-by-state information around telehealth is the Center for Connected Health Policy, which is a national telehealth policy resource center (www.chpca.org). This website allows you to look up state-specific telehealth laws, regulations, and reimbursement policies.

What Pre-Visit Paperwork Do We Need?

At our clinic, we are using two forms that we go over with the family during our initial phone intake and one document that we send to the family. The first form is a Consent to Participate in Telemental Health Treatment. This form covers important considerations for the family such as the purpose of the telehealth visits, what the visits will look like, confidentiality, potential risks, family rights, and communicating that it would be a billed visit. I have been emailing a copy of the consent form to the families in advance of our initial phone intake so they have a chance to review it. Then I get verbal consent after we review the form over the phone. I recommend that you also get the parents to sign the form and send back to the clinic via email, snail mail, or other document transfer.

The second form is a standardized screener which helps me to collect information about the family to ensure that the family is able (insurance-wise) and ready (endorsed interest, has home technology available, has safety measures in place) to initiate treatment via telehealth. The screener includes important questions like:

Which internet-connected device(s) do you have available for the telehealth visit?

Do you have any safety concerns that would prevent safe clinic-to-home telemedicine appointments (see below for more on this).

What alternative ways can I contact you if our telehealth visit gets disrupted?

The last document is a step-by-step user guide (with images) that I send to the family that outlines for them how to access the telehealth visit from their side. This will be a new technology for many of our families so you need to ensure that they have guidance that is clearly spelled out in a step-by-step manner.

How Do We Make Sure Visits Will Be Safe?

You need to prepare, in advance, a plan that is designed to keep our families safe during a telehealth visit. I go over safety planning as part of my initial phone intake. This includes confirming that the family feels like they can safely participate in the session, that there is a designated space that they can conduct the visit, environmental considerations/modifications, and preemptively gathering safety contacts (e.g., local hospital/ER, police telephone for local 911, other community crisis contacts). Keep in mind, if a patient enters into a crisis during the telehealth visit, you cannot call 911 because that would be connected to your own location. You need to be able to contact the resources that will be local to the family.

What Should Our Telehealth Room Look Like?

Lastly, there are considerations around the “cosmetics” of conducting a telehealth visit. Here are some nuggets to keep in mind:

Conduct the visit in a room that ensures privacy.

Avoid cubicles, open offices or other places that people may walk in on you or by you in the background.

Have your webcam set up in a way that allows you to see “eye-to-eye” with your patient.

Lighting is important. Don’t have your room so dark that patients can’t see your face or so bright that it washes you out.

Have a simple background behind you and avoid “busy” clothing (both are distracting on the screen).

Hopefully that’s enough information to get you started! Come back next week and we’ll dive into the “Nuts and Bolts of Delivering RUBI Sessions via Telehealth.” In the meantime, keep washing those hands, practicing physical distancing, and keeping yourself safe and healthy😊